Challenges of Cashless Mediclaim

Rakesh Goyal, Director, Probus Insurance

Medical expenses have been spiking since the past few years. Moreover, one cannot ignore the inflated medical bills that were evident during this ongoing pandemic. Under such situations, having a mediclaim policy comes in handy as it keeps you and your family stress-free and financially equipped during any medical emergencies. The coverage offered by these policies helps you overcome the expenses that otherwise would have to be paid out of your pocket.

Another significant benefit of such policies is the cashless mediclaims. This enables the insured to avail cashless treatments without having to worry about paying the medical bills. The insurer partners with specific hospitals (also known as ‘Network Hospitals’), and when the insured visits these hospitals, the medical bills could be settled without any hassle. These procedures are easier than the reimbursement policies as you do not have to pay anything from your pocket and not stress around the insurer’s process for the reimbursement.

As it is rightly said that, “There are always two sides of a coin”, similarly these policies come with its sets of both pros and challenges. As you scroll through this article, you will learn more about some of the challenges of cashless mediclaim.

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Partial claim settlement

In certain situations, the insurer would pay only for a specific portion of treatment cost as cashless settlement and would reimburse the pending amount later. Under such a situation, the insured will have to pay the pending amount from his or her pocket and later get it reimbursed from the insurance company.

Not able to find the cashless treatment hospitals

In order to be eligible to get the benefits of the cashless treatment, the insured must visit the network hospitals. It’s advisable to keep a note of all the network hospitals near your vicinity so as to be prepared during any medical emergency. If you are not able to find the network hospitals or your TPAs need additional time to process your cashless mediclaim, then under both these conditions, the insured has to bear the cost and later get the paid amount reimbursed from the insurer.

Overall duration for the process

Time can be one of the challenges while settling cashless mediclaims, especially during emergency cases. Here, the TPAs might take longer for the entire approval process, and that might lead to a delayed treatment process. In order to avoid any delay, the insurer might ask the insured to make the payments of the medical bills from their pocket and later get it reimbursed from the company.

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Documentation can be sometimes daunting

Failing to provide the required documents on time can lead to various challenges during the claim process. Not being able to fill and submit the forms may disturb and hamper the initiation of the cashless claim process.

Expenses uncovered under cashless claims

There are certain treatment costs (also known as exclusions) that are not covered under cashless claims. Those expenses include regular check-up expenses, charges for documentation, service or registration charges etc. One must take this pointer into consideration, read the policy document well in advance and understand the inclusions/exclusion so as to avoid any unpleasant surprises later during the claim process.

Also Read: Changes you Need to Make in your Insurance Plan after Marriage


The bottom line is that one must strategically make use of such cashless treatment options and adhere to the requirements of the plan to ensure a smooth claim process. Also, ensure that you have the list of your network hospitals in your locality handy and get admitted there in case of any medical treatment to avail the benefits of these cashless claims. Lastly, compare the various plans or insurers available online and pick the ones that best suit you and your family’s medical needs.

Views expressed in this article are the personal opinion of Rakesh Goyal, Director, Probus Insurance.

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